That is a claim Livonia, Mich.-based Trinity Health makes in a public activism campaign it launched this year to end the portrayal of smoking in movies — and most especially in youth-rated films.

Studies have shown that the more that youth see smoking on-screen, the more likely they are to start smoking.

The crux of the smoke-free movies campaign Trinity debuted just prior to Oscar night Feb. 26 was an e-letter-writing push that found hundreds of people sending thousands of letters to top Hollywood studio heads. The missives urged the Motion Picture Association of America to update its criteria for awarding future films an "R" rating, to include any depiction or implication of tobacco use, with a few exceptions, including for biographical portrayals of people who used tobacco and for portrayals that show the serious health consequences of smoking. According to the Motion Picture Association of America, an R rating indicates that the film contains some adult material, and "parents are urged to learn more about the film before taking their young children with them."

Trinity's ongoing campaign includes continuing conversations between health system and movie industry leaders, as well as petition drives and educational campaigns by Trinity hospitals.

In August, Trinity joined the American Academy of Family Physicians, the American Academy of Pediatrics, the American Cancer Society, the American Heart Association and a dozen other groups as a signatory to a letter to film industry executives, reinforcing the case for the R rating. The letter was spurred by a July 2017 report from the Centers for Disease Control and Prevention, confirming the dangerous influence on the impressionable from tobacco use on-screen.

"We as a health care provider are interested in getting at the root causes (of disease), and we know that we can't just start in our clinics and hospitals," said Kendall Stagg, who at the time of his interview with Catholic Health World was Trinity's director of safety net transformation and innovation. (He has since departed Trinity.) "This work has to get to where people live and impact how they live. We know the environment around us drives health outcomes, and that includes the social context, including movies."

Early gains
The CDC says smoking is the leading cause of preventable death in the U.S. About 36.5 million adults smoke; and thousands of young people start smoking cigarettes every day.

Trinity has made tobacco use prevention one of its top public health priorities. Its advocacy work on the local, state and federal levels includes a push to set the legal age for obtaining tobacco at 21.

Cathy Rowan manages Trinity's activity with the Interfaith Center on Corporate Responsibility, a coalition of faith-based organizations promoting social justice through shareholder activism. Rowan said Trinity's shareholder advocacy work on the tobacco in movies issue began around 2003 when, in coordination with the Interfaith Center, it started filing shareholder proposals with the companies that own the top Hollywood studios and voicing its concerns at their shareholder meetings. Trinity's main message: Eliminate tobacco depictions in youth-rated films.

In part because of such activism by Trinity and others, between 2005 and 2013, all the major studios and movie companies — Disney, Time Warner, Comcast, Sony, 21st Century Fox and Viacom — developed tobacco policies for their studios, including policies saying they would not enter product placement agreements with tobacco companies.

The policies seem to have produced some significant results, according to information in "Smoking in Top-Grossing U.S. Movies, 2016," a report released in June by the Center for Tobacco Control Research and Education at the University of California San Francisco. The number of youth-rated films with smoking declined by 61 percent between 2002 and 2016, the report says.

Lost momentum
But Rowan said the studios' initial enthusiasm for compliance has waned; studios have taken advantage of the fact that there are no teeth in the policies.

The UCSF center's study said that there has been no substantial change in the number of smoking scenes in movies since about 2011, but "if the rate of change observed pre-2010 had persisted, youth-rated moves would have been entirely smoke free by early 2015."

The U. S. Surgeon General has pointed to a causal relationship between depictions of smoking in the movies and the initiation of smoking among young people.

A fact sheet Trinity compiled and disseminated as part of its smoke-free movies campaign states that 37 percent of youth smokers are recruited to smoking because they saw it in the movies, and this makes movies "the single largest stimulus for youth smoking." Jonathan Polansky, a consultant with the UCSF Center for Tobacco Control Research and Education, who authored the report on smoking and movies, cites numerous studies that prove this recruitment effect, regardless of the context of the tobacco use portrayals.

The fact sheet says 5.6 million youth alive today are projected to die from tobacco-related illnesses if current trends continue; and that rate could be cut by 18 percent if youth-rated films became smoke-free. That is the calculation behind the claim that the rating change could save about 1 million lives.

Teeing off the Oscars
Trinity's Stephanie Helton, manager of communications and grassroots advocacy, ran the social media aspects of the system's "Week of Action," a concentrated push to advance the smoke-free movies initiative during the week of Feb. 19, which was the week preceding the Academy Awards.

The system provided its facilities with tool kits, including emails and newsletter articles for reaching employees; op-eds and fliers for reaching the public; and social media messages and graphics for use on Twitter, Facebook and other channels. Trinity has 93 hospitals and a network of other health care facilities spanning 22 states.

The communications encouraged people to visit Trinity's website to fill out a form that would enable them to easily send messages urging a change to movie-rating criteria.

Helton said more than 800 people sent more than 5,000 e-letters to executives at 21st Century Fox, Comcast, Sony, Time Warner, Viacom, Disney and the Motion Picture Association of America.

Coming features
Rowan and other Interfaith Center representatives have been meeting periodically with Hollywood executives since Trinity's shareholder advocacy efforts began more than a decade ago; they now are engaging in a fresh round of meetings, asking for renewed momentum and results.

Trinity facilities will continue pushing out information on the anti-smoking initiative to employees and the public. Some hospitals are collecting signatures on petitions urging the establishment of the new rating criteria. In addition, the petitions call on movie studios to certify they will not accept payment for tobacco product placements and demand that movie theaters reject ads for tobacco products. And the petitions call on states to withhold movie production tax incentives and other perks used to attract moviemakers when a film will include smoking.

Rowan said Trinity is doubling down on its anti-smoking initiatives. "We're taking a comprehensive approach to apply public pressure," she said.